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From "3 by 5" to Universal Access
Kevin M. De Cock
Director, HIV/AIDS Department
25 Years of AIDS
Epidemiologic Notes and Reports:
Pneumocystis Pneumonia --- Los Angeles
In the period October 1980-May 1981, 5 young men, all active homosexuals, were treated for biopsy-confirmed
Pneumocystis carinii pneumonia at 3 different hospitals in Los Angeles, California. Two of the patients died. All 5
patients had laboratory-confirmed previous or current cytomegalovirus (CMV) infection and candidal mucosal
infection. Case reports of these patients follow.
10 Years of HAART
From "3 by 5" to Universal Access:
outline
Current status of HIV/AIDS treatment
in the world
Role of the health sector in working
towards universal access
Conclusions
Dr LEE Jong-Wook
1945-2006
Antiretroviral therapy coverage in low- and
middle-income countries, June 2006
Geographical region Number of people Estimated need Coverage
receiving ARV
therapy
Sub-Saharan Africa 1 040 000 4 600 000 23%
Latin America and the
345 000 460 000 75%
Caribbean
East, South and South-East
235 000 1 440 000 16%
Asia
Europe and Central Asia 24 000 190 000 13%
North Africa and the Middle
4 000 75 000 5%
East
Total 1 650 000 6 800 000 24%
20 low- and middle-income countries in sub-Saharan Africa, Asia,
Latin America and the Caribbean treated more than 50% of those
in need, June 2006
ARV Therapy: global need, June 2006
5 70% of the total unmet need
(Number of people in millions)
4
Unmet need
3
Receiving ARV therapy
2
1
Sub-Saharan Latin America and East, South and Europe and North Africa and
Africa the Caribbean South-East Asia Central Asia the Middle East
Women's access to HIV treatment, June 2006
Mozambique
Uganda
Nigeria
Malawi
Zimbabwe
Zambia
Central African Republic
Botswana
Kenya
Côte d'Ivoire
Namibia
Rwanda
United Republic of Tanzania
Burundi
South Africa
10% 20% 30% 40% 50% 60% 70%
Percentage of adults on ART who are women Percentage of HIV-infected persons who are women
Children's access to HIV treatment, June
2006
Africa Latin America Asia
Median: 8% Median: 8% Median: 5 %
Access to PMTCT services in sub-Saharan
Africa, 2005
80
Percentage of HIV-infected pregnant women
Togo receiving ARV prophylaxis for PMTCT
Namibia
70 Zambia
Guinea Bissau
60 Benin
Central African Republic
50 Swaziland
Burundi
(Percentage coverage)
Uganda
40
Gabon
Rwanda
30
Kenya
Zimbabwe
20 Lesotho
Mozambique
Côte d'Ivoire
10
Treatment access among IDU in Eastern
Europe
100 IDU as % of people living with HIV
IDU as % of people on ART
90
80
70
60
50
40
30
20
10
Moldova Estonia Ukraine Serbia Lithuania Croatia Russian Czech
and Federation Republic
Montenegro
Equity of treatment access
– knowledge gaps
Coverage and quality of care in:
Time
Place
Person
Estimated total annual resources available
for AIDS, 1996–2005
9 000
8 000
7 000
6 000
5 000
PEPFAR
4 000
( US$ millions )
3 000
Global Fund
World Bank MAP Launch
2 000
Signing of Declaration of
1 000 Commitment on HIV/AIDS
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Source: Lancet, 2006; 368: 526–30
Prices of ARV therapy
Comparison of outcome in patients on ART in
high- and low-income settings
18 programmes in Africa, Asia, South
America (4,810 pts), 12 cohorts from Europe
and North America (22,217 pts)
Low-income patients:
- More females (51% vs 25%)
- Lower CD4+ (108 vs 234 per cu mm)
- More NNRTI (70% vs 23%)
Source: ART-Link and ART-CC Groups; Lancet, 2006
Comparison of mortality in the months after
starting ART in low- and high-income
settings
16
Adjusted hazard ratios
8
(Log scale of mortality rate %)
4
2
1
0.5
1 2 3 4 5 6 7 8 9 10 11 12
(Months from starting HAART)
Source: ART-Link and ART-CC Groups; Lancet, 2006
WHO: public health approach to initiating ART
WHO CLINICAL CD4 TESTING NOT CD4 TESTING AVAILABLE
STAGING AVAILABLE
1
Do not treat Treat if CD4 count is below 200
cells/mm3
2
3 Treat Consider treatment if CD4 count
is below 350 cells/mm3 and
initiate ART before CD4 count
drops below 200 cells/mm3
4 Treat Treat irrespective of CD4 cell
count
Source: WHO guidelines on antiretroviral therapy for HIV infection in adults and adolescents in resource-limited
settings: towards universal access
Recommendations for a public health approach, 2006 revision
Mortality in patients on ART in low-income
settings
73% deaths occurred in persons starting
therapy at CD4+ <100 per cu mm
38% deaths occurred in first month, 80% in first
4 months
Source: ART-LINC and ART-CC Groups, Lancet, 2006
User fees and treatment outcome
1. Meta-analysis of 10 studies by Ivers LC et al.:
Free laboratory testing did not affect outcome
Free treatment was associated with 29-31%
increase in viral load suppression
Source: Ivers LC et al., CID, 2005
2. ART-LINC:
75% lower mortality at 1 year with free treatment
Source: ART-LINC, Lancet, 2006
Countries implementing WHO HIV ResNet
Drug Resistance protocols
Resistance map
Tuberculosis in patients on ART
1. Incidence
Six countries: 3.0 – 17.6 per 100 py
South Africa: 3.4 per 100 py (CD4+ <200)
1.7 per 100 py (CD4+ 200-350)
2. Recurrence
Côte d’Ivoire: 11.0 per 100 py
Sources: Badri et al., Lancet, 2002; Seyler et al., Am J Respir Crit Care Med, 2005; Bonnet et al., AIDS, 2006
Priorities to reduce mortality of HIV/AIDS
patients in low-income settings
Expand HIV testing for earlier diagnosis
Ensure essential package of care for HIV-infected
patients, including TB screening and co-trimoxazole
Provide ART for Stages 3 and 4 disease as early as
possible
Expand CD4+ testing for earlier initiation of ART
Abolish user fees
Universal Access
2005 G8 Summit at Gleneagles, Final Communiqué:
“…working with WHO, UNAIDS and other international
bodies to develop and implement a package of HIV
prevention, treatment and care, with the aim of as
close as possible to universal access to treatment for
all those who need it by 2010.”
The health sector's contribution to achieving
Universal Access
S
T
Expanding testing and counseling R
A
T
E
G
Maximising Accelerating I
C
prevention treatment scale up
I
N
F
OR
M
Strengthening health systems A
T
I
ON
AIDS cases, deaths and persons living with
AIDS in the United States, 1985-2003 (CDC)
90 Persons living with AIDS 450
(Persons living with AIDS in thousands)
(AIDS cases and deaths in thousands)
80 400
70 AIDS Cases 350
60 300
50 250
40 200
Deaths
30 150
20 100
10 50
0 0
1985 1987 1989 1991 1993 1995 1997 1999 2001 2003
Years
Health systems strengthening
WHO framework for monitoring the health
sector: components of access
Availability: Coverage: Impact:
reachable and people using reduction in new
affordable ser- the intervention infection rates
vices that meet among those and improved
a minimum who need it survival of
standard those infected
Health
interventions
Testing and Counseling
Uganda Lesotho Kenya
Family VCT Universal TC Provider-initiated
TC
Routine HIV testing in Botswana
Routine testing in health care settings with right to
decline was introduced in 2004
1 268 adults were interviewed
81-93% were in favour, said testing would be
facilitated, treatment access enhanced
98% of persons tested expressed no regret
Principal reasons for not testing:
- fear (49%)
- "no reason to believe infected" (43%)
Source: Weiser SD et al, PLOS Medicine, 2006
Working towards universal access by 2010
Towards Universal Access
Towards Universal Access
